Florida Department of Health Guidance Against Trans Youth Healthcare Contains False Statements and Misrepresentations and Should Not Be Used by Anyone
On April 20, 2022, the Florida Department of Health published three nonbinding documents containing sweeping and inaccurate claims about transgender youth and gender-affirming care: the press release “Florida Department of Health Releases Guidance on Treatment of Gender Dysphoria for Children and Adolescents”; the PDF “Treatment of Gender Dysphoria for Children and Adolescents”; and the PDF “Treatment of Gender Dysphoria for Children and Adolescents — Fact Check”. These documents are sloppily written, typically citing either low-quality opinion sources or selectively quoting from sources that clearly contradict the position FLDOH is attempting to support, and at times referring to documents that are not about even about children and adolescents.
The FLDOH misrepresents brief opinion pieces from individual authors in Catholic and psychoanalytic journals as constituting reliable literature reviews of existing knowledge on transgender healthcare and development. FLDOH makes invalid assumptions about desistance of childhood gender dysphoria at adolescence, misrepresents its clinical relevance, and then offers advice far beyond what this evidence supports. And the FLDOH simply lies about numerous national health authorities in the United States and abroad agreeing with the department’s entirely unsupported anti-trans guidance.
These documents represent another disgraceful failure of the FLDOH under the DeSantis administration to fulfill its basic mission of providing reliable, high-quality health information to all citizens of Florida. The fact is that everyone in the state, cis or trans, whether they care about transgender issues or not at all, is now being subjected to another insulting disservice from a department that is already bleeding credibility in the COVID-19 crisis, particularly under the leadership of state surgeon general Joseph A. Ladapo. What they’ve passed off as guidance here is nothing but an embarrassment, and its fatal flaws will be visible to anyone who bothers to follow its sources. Those sources are examined here.
FLDOH guidance against social transition, puberty blockers, or HRT for minors is not supported by cited documents from CMS, Sweden, Finland, England, or France
The FLDOH document “Treatment of Gender Dysphoria for Children and Adolescents” states:
Social gender transition should not be a treatment option for children or adolescents. Anyone under 18 should not be prescribed puberty blockers or hormone therapy. Gender reassignment surgery should not be a treatment option for children or adolescents. . . . The Department’s guidelines are consistent with the federal Centers for Medicare and Medicaid Services age requirement for surgical and non-surgical treatment. These guidelines are also in line with the guidance, reviews, and recommendations from Sweden, Finland, the United Kingdom, and France.
Medicare coverage decision, 2021
FLDOH links to the federal Centers for Medicare & Medicaid Services Medicare Coverage Database article “Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)” (2021). The cited CMS article does not say anything about social gender transition or use of puberty blockers for children or adolescents, so the FLDOH’s guidance here is not “consistent” with CMS on “non-surgical treatment”. Policy and decisions made by CMS apply to coverage of treatments by Medicare and Medicaid, and the cited document is not a review of the literature informing transgender care across our lifespan, nor is it intended to be applied as clinical guidance for all medical providers at any step of transition care. CMS states the following as requirements for hormone therapy, not social transition (non-medical changes of name, pronouns, and gender presentation such as attire or hairstyle) or puberty blockers:
The criteria for cross sex hormone therapy are as follows:
1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Member must be at least 18 years of age;
4. If significant medical or mental health concerns are present, they must be reasonably well controlled.
Medicare and Medicaid coverage of hormone therapy under this policy would require a trans person to be “at least 18 years of age”, while also requiring that they have “Persistent, well-documented gender dysphoria”. Trans people who reach the age of eligibility for hormone therapy under this policy will thus be expected to have experienced persistent gender dysphoria for some time before age 18. FLDOH guidance asserts that these youth who are suffering the distress of persistent gender dysphoria would not be allowed to ameliorate this suffering even by transitioning socially in that indefinite time, a prohibition which is not made anywhere in the cited CMS document.
Sweden National Board of Health and Welfare (Socialstyrelsen), March 2021
FLDOH describes the present guidance as “in line with the guidance, reviews, and recommendations” from Sweden and links to the March 2021 document “Good care of children and adolescents with gender dysphoria — National knowledge support” from the National Board of Health and Welfare, or Socialstyrelsen. But the Socialstyrelsen document repeatedly recommends comprehensive assessment for possible treatment of trans youth with puberty blockers and cross-sex hormones — it is not at all consistent with the FLDOH guidance against puberty blockers, hormone therapy, or even social gender transition for anyone under 18. This is what Socialstyrelsen states on counseling and therapy for trans, gender-dysphoric and gender-questioning youth (via Google Translate):
Counselling, including psychotherapy and psychosocial support, is a prerequisite for quality care of gender dysphoria. During the assessment phase, access to counselling is crucial in order to promote well-founded decisions about gender reassignment treatments. Another reason is that treatment of gender dysphoria, though well-desired by the individual, often brings about medical and social strains. The patients as well as their relatives may need psychological and social support to deal with such strains. Patients may need such counselling during but also after gender reassignment treatments.
In contrast, under the FLDOH’s guidance, there would be no well-founded decisions to be made about gender reassignment treatments because those treatments would always be ruled out from the start. There would be no during or after such treatments, because there would be no treatments for anyone under 18. Page 110 of the Socialstyrelsen publication reads:
A precautionary principle, on the other hand, must not be so dominant that it leads to unacceptable consequences such as forcing patients to remain in a gender that they find foreign. For gender dysphoria among children and adolescents, it is then a matter of a young person being denied a period of adolescence in the gender that constitutes their identity: “Why should I not have a period of adolescence in the body with the gender I identify with?” A tangible and difficult suffering in a group of patients thus means that it may be inevitable to take certain risks, but it must be done in a transparent manner before the patient and so that the patient’s well-informed consent plays a decisive role.
This guidance emphasizes that trans children and adolescents must be fully informed of the risks that accompany these treatments so that they can meaningfully consent to that decision; it says nothing about such treatments being off the table for all trans youth under any circumstance. Instead, it says that forcing patients to remain in a gender that they find foreign is an unacceptable consequence. Page 112 describes conditions for offering cross-sex hormone therapy to youth:
This applies in particular to the issue of treatment with sex-opposite hormones, where more necessary conditions are specified. Gender dysphoria should be “diagnostically confirmed” and gender identity should be “strongly rooted”. Furthermore, the youth must demonstrate “mental maturity as well as knowledge and understanding of what results can be expected” and “in terms of possible medical and social risks and benefits”. In addition, “any psychological, medical and social problems” must have been considered and assessed so that they do not interfere with treatment. Of course, there are difficult trade-offs in relation to all these conditions, but they constitute reasonable positions based on a precautionary principle. They have not allowed this principle to become so rigorous that it does not take into account the profound identity problems that it entails when a young person has to develop gender characteristics in a gender to which the person is a stranger.”
According to FLDOH guidance, there would be no conditions under which this treatment is acceptable for youth; according to the Socialstyrelsen recommendations cited by the FLDOH guidance, “profound identity problems” result “when a young person has to develop gender characteristics in a gender to which the person is a stranger.”
Socialstyrelsen offers specific recommendations for prescribing puberty blockers without delay as well as hormone therapy:
- p. 52: “For adolescents with gender dysphoria, an approaching puberty means a great deal of mental strain. Healthcare should offer adolescents anti-puberty hormone therapy to reduce suffering. Older adolescents should also be offered treatment with sex-resistant hormones to initiate pubertal development that is consistent with gender identity.”
- p. 54: “The National Board of Health and Welfare’s recommendations: The health service should: ensure that treatment with puberty-inhibiting hormones is initiated without delay when the indication for treatment is established by the responsible psychiatrist; ensure that treatment with puberty-inhibiting hormones by adolescents with probable or confirmed sex dysphoria continues during the investigation thereafter, unless there are special reasons or if the conditions for treatment with anti-puberty hormones have changed.
- p. 55: “According to international guidelines and Swedish practice, young people with gender dysphoria should, under certain conditions, be offered hormone treatment at an early stage in order to slow down the development of puberty in the birth sex. A basic precondition for care to offer the intervention is that the gender dysphoria is probable or ensured. In addition to this, the youth must, as a minimum, have reached Tanner stage 2 in their puberty development, as gender dysphoria after the onset of puberty is more likely to persist over time. For many young people, the development of puberty leads to an increase in gender dysphoria, which is considered to be diagnostically important information. However, there are young people who have suffered from gender dysphoria for a long time and who have an obvious need for care without simultaneously reporting such an increase. An increased gender dysphoria in connection with the development of puberty should therefore be seen as something that strengthens the indication for treatment but not as a necessary medical criterion.”
On page 62, Socialstyrelsen states that youth may receive hormone therapy at 16 or earlier and should have already socially transitioned for some time:
In order for young people to be able to receive gender-opposite hormone treatment, it is required that gender dysphoria is ensured. Gender identity must be well established, which may mean that young people have lived socially in accordance with their gender identity since the onset of puberty-inhibiting treatment. The youth may also have consolidated their gender identity in other ways. Alternative explanations must have been excluded during the course of the investigation. The youth must have matured enough to understand what changes can be expected from a gender-opposite treatment and what medical and social consequences the treatment can entail. This is often expected to happen at the age of 16, but it can happen sooner or later.
Nothing about the guidance from Sweden cited by the FLDOH supports the department’s guidance that no one under 18 should socially transition or receive puberty blockers or hormone therapy.
COHERE Finland recommendation, June 2020
The FLDOH links to the June 11, 2020 recommendation “Medical treatment methods for dysphoria associated with variations in the gender identity of minors” by the Council for Choices in Health Care in Finland (COHERE Finland). However, contrary to the FLDOH guidance, the COHERE Finland recommendation lays out specific criteria for prescribing puberty blockers and hormone therapy to minors (via Google Translate):
If a pre-pubertal person has a clear symptom of sexual dysphoria before the onset of puberty that intensifies during puberty, he or she may be referred to the TAYS or HUS Gender Identity Research Group for evaluation of treatment that inhibits the progression of puberty. If no contraindications to early intervention are identified, inhibition of puberty with GnRH analogues (a drug that inhibits gonadotropin-releasing hormone activity) may be considered to prevent the development of secondary sex characteristics by biological sex. Adolescents who have already undergone puberty, who develop sexual anxiety but no other symptomatic symptoms requiring concomitant psychiatric care, and whose transgender experience is not lost with the opportunity to reflect their identity, may be referred to gender identity studies in the TAYS or HUS minority studies. Conversion hormone therapy (testosterone / estrogen and antiandrogen) should not be initiated until 16 years of age after diagnostic tests. In addition, GnRH analogue therapy, which blocks the hormonal function of their own gonads, is often started 3 to 6 months before conversion to hormone therapy.
These recommendations describe early use of puberty blockers and use of hormone therapy starting from age 16. It is not a recommendation against puberty blockers, hormone therapy, or social transition for anyone under 18.
NHS England Cass Review interim report, February 2022
FLDOH links to the Cass Review (“Independent Review of Gender Identity Services for Children and Young People”) commissioned by the English NHS. The interim report of this ongoing review, contradicting FLDOH guidance, recommends an expansion of services for trans and gender-questioning youth to provide more timely care, including ongoing counseling as well as possible assessment for puberty blockers or hormone therapy. The report states:
Any child or young person being considered for hormone treatment should have a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental and psychosocial wellbeing. This formulation should then inform what options for support and intervention might be helpful for that child or young person.
This explicitly describes gender-affirming medical treatment as a possible option for children and young people, something under consideration — not something categorically ruled out as in the FLDOH guidance. The interim report recommends following up youth receiving these treatments within formal protocols in order to acquire better data; it does not recommend stopping such research in its tracks:
Prospective consent of children and young people should be sought for their data to be used for continuous service development, to track outcomes, and for research purposes. Within this model, children and young people put on hormone treatment should be formally followed up into adult services, ideally as part of an agreed research protocol, to improve outcome data.
The report calls for a significant expansion of services to assess these youth and reduce waiting times:
A fundamentally different service model is needed which is more in line with other paediatric provision, to provide timely and appropriate care for children and young people needing support around their gender identity. This must include support for any other clinical presentations that they may have. The Review supports NHS England’s plan to establish regional services, and welcomes the move from a single highly specialist service to regional hubs. Expanding the number of providers will have the advantages of: creating networks within each area to improve early access and support; reducing waiting times for specialist care; building capacity and training opportunities within the workforce; developing a specialist network to ensure peer review and shared standards of care; and providing opportunities to establish a more formalised service improvement strategy.
And the report describes how to obtain informed consent from trans children and adolescents for treatment with puberty blockers:
Given the uncertainties regarding puberty blockers, it is particularly important to demonstrate that consent under this circumstance has been fully informed and to follow GMC guidance by keeping an accurate record of the exchange of information leading to a decision in order to inform their future care and to help explain and justify the clinician’s decisions and actions. . . . Within clinical notes, the stated purpose of puberty blockers as explained to the child or young person and parent should be made clear. There should be clear documentation of what information has been provided to each child or young person on likely outcomes and side effects of all hormone treatment, as well as uncertainties about longer-term outcomes.
None of this is in agreement with FLDOH’s guidance that minors should be barred from puberty blockers, hormone therapy, and even socially transitioning.
France National Academy of Medicine (Académie nationale de médecine) press release, February 2022
The FLDOH cites a press release by France’s Académie nationale de médecine on “Medicine and gender transidentity in children and adolescents”, yet this press release also describes conditions under which youth should access puberty blockers or hormone therapy:
The National academy of medicine draws the attention of the medical community to the increasing demand for care in the context of gender transidentity in children and adolescents and recommends:
– A psychological support as long as possible for children and adolescents expressing a desire to transition and their parents;
– In the event of a persistent desire for transition, a careful decision about medical treatment with hormone blockers or hormones of the opposite sex within the framework of Multi-disciplinary Consultation Meetings;
The Académie has not called for withholding all access to puberty blockers or hormones for anyone under 18, and it hasn’t said anything about social transition. So the Florida Department of Health is 0 for 5 in citing Medicare, Sweden, Finland, England, and France as supporting its recommendations against social transition, puberty blockers, or gender-affirming hormone therapy.
FLDOH anti-trans guidance attacks “low-quality evidence” for gender-affirming care, citing low-quality evidence for conversion therapy
The Florida Department of Health writes:
Systematic reviews on hormonal treatment for young people show a trend of low-quality evidence, small sample sizes, and medium to high risk of bias.
Hruz (2019) is not a systematic review
The linked “systematic reviews” is actually one four-page article by Paul W. Hruz (2019) in the Catholic Medical Association’s journal The Linacre Quarterly, and it is not a systematic review. It broadly encompasses the spectrum of gender-affirming care across all ages and does not specifically focus on “hormonal treatment for young people”. The journal has published it as a “research article”, and it is an unorganized continuous wall of text:
It does not possess any of the expected features of a systematic review, such as a specific research question or discussion of search criteria for inclusion of studies (Robertson-Malt, 2014). The FLDOH has erred in labeling this a “systematic review”.
In the same issue of The Linacre Quarterly, Kissell (2019) describes assisting with abortions as a cooperation with evil, McTavish (2019) lists “gender confusion” among “areas for pediatricians specifically to exercise their prophetic task as physicians and relative to medicine”, Williams (2019) argues for the inferiority of same-sex parents and for a slippery slope toward “polyamorous families”, and Reno (2019) describes suffering as “clarifying” and asserts: “We are often dead to spiritual things, and sometimes it takes the looming threat of suffering and death to awaken us.”
The norms of this journal are likely to inform the standards and values that journal contributor Hruz applies in his assessment of the adequacy of gender-affirming care for transgender and gender-questioning youth. Do those have the potential to include positions such as transness as “confusion”, the pediatrician as Catholic “prophet”, judgment of same-sex couples as potentially harmful to children, and suffering as spiritually beneficial?
The FLDOH’s choice to cite a low-quality article in a Catholic medical journal as informing state health policy and recommendations has raised these questions unnecessarily (assuming higher-quality evidence from less-biased sources was available). What is the quality of this evidence? What is the risk of bias? Is it low, medium, or high?
Hruz incorrectly cites Cohen-Kettenis & Kuiper (1984) as supporting gender identity change efforts (conversion therapy)
Since the widespread adoption of interventional strategies directed toward affirming transgender identity, efforts to identify psychological approaches to mitigate dysphoria, with or without desistance as a desired goal, have largely been abandoned. The WPATH has rejected psychological counseling as a viable means to address sex–gender discordance with the claim that this approach has been proven to be unsuccessful and is harmful (Coleman et al. 2012). Yet the evidence cited to support this assertion, mostly from case reports published over forty years ago, includes data showing patients who benefited from this approach (Cohen-Kettenis and Kuiper 1984). Although largely unstudied, cognitive behavioral therapy in particular may have significant benefit to this patient population by reducing social anxiety (Busa, Janssen, and Lakshman 2018).
However, coauthor Peggy Cohen-Kettenis made clear in chapter 6 of Smith (2002) that her 1984 review did not support gender identity change efforts over gender-affirming care:
In 1984, Cohen-Kettenis and Kuiper reviewed the existing case studies at that time. They concluded that the evidence for complete and long-term reversal of cross-gender identity by means of psychotherapy was not convincing for the following reasons. Firstly, in each report gender identity was operationalized differently. Consequently, treatment success was assessed on the basis of various, and sometimes unspecified, criteria. Secondly, some patients reported a disappearance of the wish for SR, when no psychotherapy was given. However, some applicants who refrain from SR may reapply many years later. So even the few claimed cures might have been postponements of SR. Thirdly, patients in these studies were highly motivated to “change“ their gender identity, which is rarely encountered in most applicants for SR. The authors did confirm, that in some cases psychotherapy had brought the transsexual to renounce their wish to undergo SR (i.e., two of the three cases from the Barlow et al. studies, 1973, 1979). In view of the scarce data available on the long-term effects of psychotherapy however, the authors considered it to be quite uncertain to conclude whether the results were manifestations of a fundamental change in cross-gender identity, or of a temporary distancing from, or perhaps suppression of the gender identity conflict. In conclusion, psychotherapy might be helpful for individuals who are merely gender confused or who’s wish for SR seems to originate from factors other than a genuine and complete cross-gender identity. Whether genuine transsexualism can be effectively resolved by means of psychotherapy still requires more conclusive evidence. Psychotherapy or counseling for purposes other than changing a cross-gender identity is also an option for SR candidates. They may, for instance, want to overcome anxieties concerning the future or need support when “coming-out“, when dealing with personal loss, or when trying to adjust to their changing life situation (Cohen-Kettenis and Gooren, 1999; Meyer et al., 2001).
This makes clear that the authors found anti-trans conversion therapy approaches to be broadly ineffective, and concluded that psychotherapy should be limited to supporting trans people in their identities and throughout any transition. Smith et al. continue:
In a recent study five cases were described of adults who were diagnosed with gender identity disorder and who showed occasional remission in gender dysphoria (Marks et al., 2000). Remission had occurred with or without treatment and in response to various life events and co-morbid psychopathology. Some of the subjects had consciously tried to suppress or control their gender dysphoria because of pressure from their partner or because circumstances did not allow for addressing the gender issue (e.g., one subject felt only minimally gender dysphoric while taking care for his aged and ill parents). Remission was documented at up to ten years. The authors concluded that, if evaluated over many years, a cross-gender identity could be less fixed than is often thought. Their implications for the clinician were that such applicants require a long trial period of cross-gender living prior to any surgical interventions. We suppose that these individuals with an apparently “less fixed” cross-gender identity might have gained from psychotherapy in coping with their gender and nongender problems. However, resolution of their gender identity conflict as a consequence of psychotherapeutic treatment seems highly unlikely, since remission of the gender dysphoria in these cases, apparently, was temporary. The fact of the matter is that the gender dysphoria in all of the five cases described in the study had returned to such an extent that the subjects had resumed cross-gender living, and all but one had started or resumed hormone treatment.
Again, the authors find it unlikely that use of psychotherapy will cause a trans person’s gender identity to resolve in the direction of cisgender identification. These reported cases of remission were rare and clinically diverse, and do not support any specific gender identity change efforts as being effective or even broadly applicable to the general gender-dysphoric transgender population. (Busa, Janssen, & Lakshman (2018) reviewed only treatment for social anxiety in transgender youth populations; disidentification as trans or remission of gender dysphoria did not even appear as subjects in that review.)
Hruz cites Zucker et al. (2012), who support gender affirmation for adolescent trans kids
The pioneering work of Zucker established that many but not all patients who received psychological counseling and support were able to manage and resolve conflicts arising from discordant gender identity, particularly in affected children (Zucker et al. 2012).
This statement neither favors nor disfavors gender-affirming care, it simply describes co-occurring conflicts being addressed regardless of whether these children would go on to identify as cisgender or transgender. However, Zucker et al. (2012) write explicitly in favor of gender affirmation for adolescent trans youth, including social and medical transition, as they consider trans adolescents unlikely to begin spontaneously identifying as cis or experiencing remission of gender dysphoria:
From a developmental perspective, we take a very different approach when we work with adolescents with GID than when we work with children with GID. This is because we believe that there is much less evidence that GID can remit in adolescents than in children. Whether this is due to different populations of clients seen in adolescence versus childhood or whether this is due to a narrowing of plasticity and malleability in gender identity differentiation by the time of adolescence is open to debate. But, if the clinical consensus is that a particular adolescent is very much likely to persist down a pathway toward hormonal and sex-reassignment surgery, then our therapeutic approach is one that supports this pathway on the grounds that it will lead to a better psychosocial adaptation and quality of life (Zucker, Bradley, Owen-Anderson, et al., 2011). Because the treatment literature is lacking in terms of rigorous comparative evaluations (e.g., Treatment X vs. Treatment Y or Treatment X vs. no treatment, etc.), one has to rely on a patchwork of empirical evidence about natural history. Thus, for example, natural history data suggest, to date, a much higher rate of desistance of GID in child samples than in adolescent or adult samples (Zucker et al., 2011).”
This contradicts the FLDOH guidance against social transition, puberty blockers or hormone therapy for anyone under 18. Zucker et al. are also deliberately ambiguous and qualitative in their descriptions of treatment “success” or “failure” or “in between”, and openly question whether resolution in favor of cisgender identity is even a successful outcome:
If one goal of treatment is to reduce the gender dysphoria, then, by definition, a successful outcome would be its remission and a failure would be its persistence. If, however, a successful outcome also takes into account a child’s more general well-being and adaptation to various developmental tasks, then the definitions of success and failure must be broader. Consider, for example, the vignette described earlier of the 7-year-old girl who had an extremely strained relationship with her father. Six years after therapy commenced (and still continues), the GID has fully remitted and there has been a lessening of the sensory sensitivities and rituals. Although this now young adolescent girl functions reasonably well at school and has friends, parent-child relations remain severely strained and there continues to be substantial parental psychopathology (in each parent and in their marriage). Success? Failure? In between?
This does not support even the insinuation by Hruz that lasting resolution toward a cis identity is possible or desirable.
Zucker’s work with gender-questioning children is not benign and enforces distressing behavioral gender-role conformity
Ken Zucker has been reported as promoting a clinical approach to childhood gender dysphoria or gender-questioning that can involve discouraging activities and behaviors stereotyped as reflective of a cross-gender identification, as well as discouraging transgender identification directly. Bailey (2003) describes Zucker as encouraging families to tell a child they must be cisgender and cannot transition:
First, he thinks that family dynamics play a large role in childhood GID — not necessarily in the origins of cross-gendered behavior, but in their persistence. It is the disordered and chaotic family, according to Zucker, that can’t get its act together to present a consistent and sensible reaction to the child, which would be something like the following: “We love you, but you are a boy, not a girl. Wishing to be a girl will only make you unhappy in the long run, and pretending to be a girl will only make your life around others harder.” . . . The second prong is therapy for the boy, to help him adjust to the idea that he cannot become a girl, and to help teach him how to minimize social ostracism.
This extends to taking toys away from children:
The third prong is key. Zucker says simply: “The Barbies have to go.” He has nothing against Barbie dolls, of course. He means something more general. Feminine toys and accoutrements — including Barbie dolls, girls’ shoes, dresses, purses, and princess gowns — are no longer to be tolerated at home, much less bought for the child. Zucker believes that toleration and encouragement of feminine play and dress prevents the child from accepting his maleness.
Imposing requirements such as these for gender-conforming play have been reported as causing significant distress in Zucker’s child patients (Spiegel, 2008):
So, to treat Bradley, Zucker explained to Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder. . . .
By the time Bradley started therapy he was almost 6 years old, and Carol had a house full of Barbie dolls and Polly Pockets. She now had to remove them. To cushion the blow, she didn’t take the toys away all at once; she told Bradley that he could choose one or two toys a day. . . .
As his pile of toys dwindled, Carol realized Bradley was hoarding. She would find female action figures stashed between couch pillows. Rainbow unicorns were hidden in the back of Bradley’s closet. Bradley seemed at a loss, she said. They gave him male toys, but he chose not to play at all. . . .
“He was much more emotional. … He could be very clingy. He didn’t want to go to school anymore,” she says. “Just the smallest thing could, you know, send him into a major crying fit. And … he seemed to feel really heavy and really emotional.” Bradley has been in therapy now for eight months, and Carol says still, on the rare occasions when she cannot avoid having him exposed to girl toys, like when they visit family, it doesn’t go well. “It’s really hard for him. He’ll disappear and close a door, and we’ll find him playing with dolls and Polly Pockets and … the stuff that he’s drawn to,” she says.
This treatment is described as inducing forms of distress in the child that did not previously exist:
In particular, there is one typically girl thing — now banned — that her son absolutely cannot resist.
“He really struggles with the color pink. He really struggles with the color pink. He can’t even really look at pink,” Carol says. “He’s like an addict. He’s like, ‘Mommy, don’t take me there! Close my eyes! Cover my eyes! I can’t see that stuff; it’s all pink!’”
The enforcement of gender-conforming behavior and identification instead pushed this very young child toward expressing their gender only through a “double life” concealed from their disapproving parents:
“I mean, he tells us now that he doesn’t dream anymore that he’s a girl. So, we’re happy with that. He’s still a bit defensive if we ask him, ‘Do you want to be a girl?’ He’s like ‘No, NO! I’m happy being a boy. …’ He gives us that sort of stock answer. … I still think we’re at the stage where he feels he’s leading a double life,” she says. “… I’m still quite certain that he is with the girls all the time at school, and so he knows to behave one way at school, and then when he comes home, there’s a different set of expectations.”
This is the distressing treatment of children approvingly cited by Hruz in the pursuit of “Success? Failure? In between?” The enforcement of gender conformity as a treatment approach is at odds with both the gender-affirmative approach and the more conservative watchful-waiting approach, which have been adopted in leading medical guidelines around the world (Ashley et al., 2019).
Hruz relies on discredited source Paul McHugh
There are a few relatively small studies that have demonstrated improved sense of well-being and reduced dysphoria in adolescent transgendered youth who receive puberty-blocking drugs (de Vries et al. 2011, 2014), but there are also significant concerns related to associated risks (Hruz, Mayer, and McHugh 2017).
His citation of Hruz, Mayer, & McHugh (2017) in the non-peer-reviewed The New Atlantis, founded by the “Judeo-Christian” conservative Ethics and Public Policy Center, highlights a significant credibility issue with his coauthor Paul McHugh. McHugh has repeatedly claimed in recent years that under his leadership at Johns Hopkins, he closed the clinic providing gender-affirming care on the basis of findings that transition care did not improve outcomes for trans patients (McHugh, 2016).
However, that 1979 study relied on an ad hoc “adjustment score” that evaluated patients’ outcomes as better if they were exclusively heterosexual and if they did not receive any of the followup psychological support which is now recommended as the standard of care in transition (Meyer & Reter, 1979). Contemporary replies identified possible numerical irregularities in the published results of the study (Fleming, Steinman, & Bocknek, 1980). McHugh would later admit his true intentions for the Johns Hopkins gender clinic under his leadership (McHugh, 1992): “It was part of my intention, when I arrived in Baltimore in 1975, to help end it.” The reliance on such sources in the course of FLDOH’s own attempt to obstruct access to transition care on the basis of misrepresentations is doubly inappropriate. (Johns Hopkins has since resumed providing comprehensive gender-affirming medical treatments via their Center for Transgender Health.)
Hruz calls for more randomized controlled trials for transition, but does not understand that this requires active controls
The limitations of the published studies in the growing field of transgender medicine are many. They include a general lack of randomized controlled trial design, small sample sizes, high potential for recruitment bias, questions regarding the precision of measured parameters, nongeneralizable population groups, relatively short follow-up, high numbers of patients lost to follow-up, and frequent reliance upon “expert opinion” alone. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on “expert” opinion.
But this does not properly contextualize how randomized controlled trials of gender-affirming care would likely be conducted and what this would be intended to accomplish. A Cochrane Library systematic review of HRT for adult trans women, cited in the FLDOH guidance, offers recommendations for more rigorous research on transition care and outcomes (Haupt et al., 2020):
Against this background, methodological problems such as inconsistent and missing comparison groups, uncontrolled confounding factors, small sample size, short follow-up time and difficulties in recording and evaluating a broad spectrum of health outcomes (physical and mental health, social functioning and QoL) have become apparent in hormone therapy (Deutsch 2016b). The performance of RCTs is controversial, especially with regard to placebo studies, and ethical and methodological objections have been raised (e.g. violation of the principle of equipoise, Miller 2003). However, the positive research potential of active-controlled RCTs is acknowledged, in order to compare different types, dosages and methods of administration of active treatments. Overall, there is a trend in the discussion to favour not only RCTs and quasi-RCTs, but also high-quality cohort studies conducted in a network of health centres, hospitals and practices (Deutsch 2016a; Deutsch 2016b).
An active-control RCT could, for example, give cross-sex hormone therapy both to the test and the control group while only varying the dosage. It is not intended to measure the effects of withholding all treatment, but to avoid the need to withhold all treatment from one group as part of a randomized controlled trial of gender-affirming care, which would be unethical or even impossible. In this case, obtaining sample sizes large enough to perform subgroup analyses by medication, dosage, route of administration, and other variables would require studies to begin enrolling many more participants to receive gender-affirming care. This would provide actionable clinical knowledge on the optimal way to provide effective hormone therapy. And it’s precisely how to obtain higher-quality evidence with a lower risk of bias — the very qualities FLDOH seeks.
The FLDOH guide to parenting: Ignore a child’s issues, and just hope it all goes away
The Florida Department of Health states:
Based on the currently available evidence, “encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm.”
In this bullet point, FLDOH cites a brief article by psychoanalytic psychologist David Schwartz (2021) outlining his personal history in clinical practice and his opinions on gender-affirming care. Like Hruz (2019), this is not any kind of systematic review of evidence. Large swathes of Schwartz’s assessment of the “currently available evidence” are merely his own assertions without any supporting references, or the most cursory sprinkling of tangentially relevant sources, and none of it constitutes an adequate summary of that evidence.
Schwartz (2021) on Mahfouda et al. (2017) on Klink et al. (2015) on bone health
Schwartz makes the following statement about possible harms of puberty blockers:
First, we do not have certainty about the harmful effects of puberty blockers as we do have for cross-sex hormone administration, because we do not have good longitudinal data on their effects in general. But we do know that puberty blockers adversely affect bone density, can instigate excessive height and adversely affect fertility. (Mahfouda et al., 2017).
The cited source, Mahfouda et al. (2017), highlights the delayed accrual of bone mass during treatment with puberty blockers and the question of whether this reaches normal levels during subsequent cross-sex hormone therapy. This source notably suggests that this should be addressed with higher doses of estrogen for adolescent trans girls:
Preliminary results of the first 21 patients (n=11 female-to-male transgender patients) with gender identity disorder to be given GnRH agonist treatment (triptorelin, 3.75 mg given subcutaneously or intramuscularly every 4 weeks) showed a significant decrease in bone accretion during puberty suppression, although bone accretion normalised during CSH treatment. Klink and colleagues retrospectively assessed BMD in a cohort of patients with gender identity disorder (n=34) who had received triptorelin monotherapy during adolescence, followed by CSH therapy in combination with triptorelin, and then surgical gonadectomy and CSH therapy as adults. . . . In female-to-male patients, areal BMD Z scores of both the lumbar spine and femoral region significantly decreased with triptorelin monotherapy, although these scores improved substantially with CSH treatment. The researchers surmised that this improvement was probably due to the rapid increase in dose increments of testosterone. By contrast, BMD Z scores did not significantly decrease during triptorelin monotherapy in male-to-female patients, although a rise in these scores was not seen following low-dose oestrogen administration. Similar results have led to the proposition that higher doses of oestrogen might be warranted in male-to-female patients.
Klink et al. (2015), cited by Mahfouda et al., offer additional caveats: “The relevance of these findings with respect to fracture risk is not clear”, and “The contribution of GnRHa treatment is at best tentative”:
Most patients were late pubertal at start and therefore part of their bone mass development had already occurred and GnRHa monotherapy therapy was relatively short before start of CSH therapy.
Mahfouda et al. go on to recommend, not that puberty blockers or hormone therapy be withheld until age 18 as the FLDOH recommends, but that bone health be monitored during this treatment:
Therefore, regular monitoring of BMD in transgender patients receiving medical treatment is recommended, in accordance with Endocrine Society guidelines. This recommended monitoring includes an examination of BMD before treatment initiation. Encouraging young transgender patients to maintain optimal bone health with adequate calcium intake, vitamin D supplementation (if indicated), and weightbearing exercise is also important.
Additionally, Mahfouda et al. describe an approach to minimize risks to bone health by shortening the time spent on puberty blockers before progressing to hormone therapy:
By contrast, some institutions have been studying the effect of adding CSH therapy to puberty-suppression treatment at age 14 years. This approach is based on the premise that keeping adolescents in a prepubertal state until age 16 years might not only compromise bone health, but also further isolate these adolescents developmentally from their peers. Similarly, in Japan, CSH therapy can be started at age 15 years.
The FLDOH’s source has relied on a publication that clearly contradicts the department’s recommendations against puberty blockers or hormone therapy for anyone under 18, and in fact recommends that hormone therapy may need to be given at even earlier ages.
Does Schwartz know what puberty blockers and hormones are?
The FLDOH’s quote of Schwartz is taken from a longer paragraph:
So my narrow purpose today is to persuade you that in the treatment of children and adolescents, no matter what the diagnosis, encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic makeup of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm.
In this passage, Schwartz has asserted that treatments such as puberty blockers “run an unacceptably high risk of doing harm” in children and adolescents no matter what the diagnosis. This would present an issue for cisgender children with precocious puberty, which is treated with the same puberty blockers used off-label for trans adolescents (Guaraldi et al., 2016). Schwartz does not cite any supporting material pertaining to the safety of puberty blockers in cis youth, and this paragraph leaves it unclear whether Schwartz is aware of basic information about puberty blockers.
Similarly, the description “hormones which are out of line with the genetic makeup of the child” appears to be based on a misunderstanding of the roles of both sex hormones and the genome in both cis and trans people. Those assigned female and those assigned male both have estrogen and testosterone present at higher or lower levels, because both hormones play important biological roles for everyone (Cooke et al., 2017), and everyone is capable of responding to those sex hormones without respect to their individual “genetic makeup”. This is the very essence of how hormone therapy works: it is not out of line with anyone’s genetic makeup, but works with the instructions coded in our DNA to cause the expression of the desired secondary sexual characteristics. Treatment with testosterone or estrogen is simply the switch — the necessary machinery was already present. Schwartz’s phrasing is needlessly confusing and possibly revealing of his lack of familiarity with this field.
Schwartz conflates childhood-onset and adolescent/adult-onset gender dysphoria
Schwartz says of treatment with puberty blockers:
In fact, the clinical articles in Drescher and Byne’s volume (2013), assert that most adolescents who undergo puberty suppression do tend to proceed to transition away from their natal sex (Stein, 2013), in contrast to the fact that the large majority of gender dysphoric children in general do not (Singh et al., 2021). It would seem that the use of puberty blockers promotes transition.
However, gender dysphoria in childhood and gender dysphoria in adolescence are two distinct entities. Childhood-onset gender dysphoria may persist into adolescent gender dysphoria or desist around the onset of puberty; adolescent/adult gender dysphoria, whether persisting from childhood gender dysphoria or appearing in adolescence for the first time, is very unlikely to desist. The cited source Stein (2012) explains exactly this:
A majority of children with GID turn out to be desisters. As adults, a majority will turn out to identify as gay men, lesbians, or bisexuals, with a significant portion of the rest becoming heterosexuals without gender dysphoria. In only a small proportion of children with GID does the condition persist from childhood and into adulthood. . . .
Second, the clinical articles in this special issue support the practice of using puberty suppression drugs for persisting gender variant adolescents, although they seem to have different thresholds for recommending or offering this course of treatment. Ehrensaft (this issue), for example, says that “children who are approaching puberty and are faced with a sudden trauma that forces to consciousness the horror that they are living in a body that is totally at odds with the gender they know themselves to be … are in gender crisis and need to be attended to immediately with an evaluation for puberty blockers … ” (p. 345). De Vries and Cohen-Kettenis (this issue) consider adolescents “eligible for puberty suppression when they are [i] diagnosed with GID [specifically “very early onset gender dysphoria that has increased around puberty”], [ii] live in a supportive environment and [iii] have no serious psychosocial problems interfering with the diagnostic assessment or treatment.” (pp. 310–311). Edwards-Leeper and Spack (this issue) consider an individual in “early or mid puberty” to be a candidate for puberty suppression when i) a clinical evaluation “indicates strong and persistent gender dysphoria and a desire [for] medical intervention,” ii) there is “no evidence of severe, untreated psychiatric conditions,” iii) his or her parents support use of puberty suppression, and iv) the individual will continue mental health counseling during treatment (p. 325). . . .
Despite the seemingly varied tests described by the clinical articles for when puberty suppression is appropriate, they seem to share the same rationale for this treatment regimen, namely to allow for a wait-and-see approach, giving gender dysphoric individuals time to experience additional emotional and cognitive maturation before they decide how they wish to deal with their gender variance. The onset of puberty seems to be a critical phase for gender dysphoric adolescents. At that stage in their physical development, some of them experience increasing distress about the development of secondary sex characteristics typically associated with their natal sex (e.g., natal males may experience distress about getting spontaneous erections and deeper voices and natal females may experience distress about developing larger breasts and the start of menstruation). Puberty suppression drugs will halt such physical developments, often relieving the distress that apparently comes from the emergence of undesired secondary sex characteristics.
This is not a contrast and it does not show that “the use of puberty blockers promotes transition”. It shows that puberty blockers are being used, not in that large majority of children, but in the smaller group of adolescents with persisting gender dysphoria that is very unlikely to remit.
“I am aware of at least one”
Citing his solo “incomplete reading of the literature”, Schwartz tells us:
Besides the obvious losses, costs and risks of these procedures, there are problems that are less immediately apparent and insufficiently emphasized in the literature of those who promote them: the surgeries are not uncomplicated. I am not aware of any tabulation of the frequency of serious complications, including fatalities; but I am aware of at least one documented fatality from my incomplete reading of the literature (de Vries et al., 2014). Testosterone is associated with significant acne (Braun et al., 2021; Thoreson et al., 2021; Turrion-Merino et al., 2015) and much more ominously, may exacerbate preexisting affective illness (Elboga & Sayiner, 2018) (a not uncommon condition in the relevant population), both of which I have observed clinically, sometimes with serious consequences; and estrogen administration to genetic males significantly increases their chances of getting breast cancer (de Blok et al., 2019).
The fatality noted by de Vries et al. (2014) was reported in greater detail by Negenborn et al. (2017) and describes a hospital-acquired infection with ESBL-producing E. coli, a type of antibiotic-resistant infection that is especially likely to be fatal (Melzer & Petersen, 2007). Because the risk of this kind of infection is not specific to gender-affirming surgery, any argument against gender-affirming surgery on this basis would require arguing against receiving surgery or going into hospitals for any purpose.
Elboga & Sayiner (2018) did not address trans patients or gender-affirming care, but was a single case report on one 17-year-old cis boy with late puberty and a history of inpatient hospitalization and treatment with antipsychotics and mood stabilizers. His case was complicated by several conditions and it is not clear why any features of this case would be broadly applicable to transmasculine adolescents. It says nothing about the nature or scale of the alleged risk to that population, and it certainly does not offer sufficient grounds to declare that gender-affirming care is firmly unacceptable for transmasculine adolescents.
While de Blok et al. (2019) reported that trans women using hormone therapy experienced a higher likelihood of breast cancer than cis men, the same study estimated that their risk is only 30% that of cis women. (This same clinic has also reported data showing that trans women on HRT have a risk of prostate cancer only 20% that of cis men (de Nie et al., 2020).)
Braun et al. (2021) state that “Isotretinoin has been used to treat moderate-to-severe acne effectively in transgender persons” and recommend “screening and treatment for acne and mental health morbidity” for transmasculine patients with acne. Thoreson et al. (2021) conclude that trans men considering testosterone “should be counseled on the increased risk of acne and the treatments available”, and Turrion-Merino et al. (2015) report on two cases of successful treatment of acne in trans men, stating: “We believe that personal susceptibility plays a crucial role in the acne development after cross-sex hormone therapy.” None of these sources conclude, however, that the risk of acne associated with HRT constitutes “an unacceptably high risk of doing harm”.
“I am telling them to be like me”: Schwartz’s parenting by “punting”
What does Schwartz recommend as an alternative approach to addressing gender dysphoria in children and adolescents? Citing his “almost ten years of experience with transgendered and gender dysphoric youth”, he describes his treatment:
I began by recognizing that the preoccupation with gender that these children and their parents were manifesting was only that, a preoccupation, and often, an obsessional preoccupation, which means that the patient felt compelled to return to it, anticipating intense anxiety if he or she didn’t, unconsciously anticipating relief when they did. Gender, an ideational configuration only, was being centralized and reified (with cultural cooperation) to function as a defense against other, unspoken dreads. This means that in each case the preoccupation with gender conceals something different, something idiosyncratic. There is no common underlying meaning to gender dysphoria. The therapeutic move I had to make was to open a space of relatedness outside of gender. In my interactions with patients I would never bring gender up, nor would I talk about it more than absolutely necessary. If the patient wanted to talk about gender I would welcome it, listen and respond enough so I didn’t seem to be evasive, but spend very little time with it in my own my mind, thinking all the while of what might really be going on for that patient. In addition I actually made an effort to experience the patient as having no gender, which I guess really meant trying to effect a kind of gender neutralizing in the way I paid attention. This is, of course, impossible, but turns out to be an excellent way of paying better attention to the aspects of a, trans child that he or she is neglecting in his or her hypercathexis of gender: intelligence, creativity, unspoken emotions, friendships. I became deeply involved with all the details of each child’s interests — TV shows, movies, songs, other kids, etc.
Schwartz has begun with the assumption that apparent gender dysphoria is always a manifestation of an “obsessional preoccupation”, and rather than being a distinct clinical syndrome, reports of gender dysphoria have “no common underlying meaning”. From the outset, this framing does not permit even the possibility that a transgender adult was once a transgender child — on the basis of Schwartz’s mere assertions, we are expected to accept that transgender youth’s identities are universally invalid because they must always originate in something other than the direct experience of gender dysphoria. In keeping with this assumption, Schwartz obliviously labels a young adult gender patient’s symptoms as due to “preoccupations” and “obsessionality”:
Interestingly, the unanticipated material that has come up has at times been marked by a high frequency of body preoccupations: a young woman is distressed at the feeling of her breasts tugged by gravity when she lies on her side; another is disturbed by the feel of her thighs touching one another while walking; a young woman hates her vagina and feels the face she sees in the mirror does not belong to her. My speculation about the role of obsessionality is receiving confirmation: I am repeatedly seeing significant obsessive-compulsive symptoms in these patients, e.g., needing to sit perfectly centered on a couch.
However, these symptoms align with criteria of the DSM-5 diagnosis of gender dysphoria in adolescents and adults, including “A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics” and “A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender” (American Psychiatric Association, 2013). What Schwartz labels as “obsessive-compulsive symptoms” have already been recognized as gender-dysphoric symptoms — the very subject he studiously avoids discussing with the patients seeing him for exactly those symptoms. He goes on to recommend parents of trans or gender-questioning youth adopt his approach of consistently avoiding this one issue, other than ignoring their child’s chosen name and pronouns:
To the parents, with whom I meet when they feel the need, and which I always encourage, I gave the emphatic advice to give intense and plentiful attention to their child, but not speak about gender at all. Listen to whatever your child has to say on the subject if they bring it up, be interested, but make no contribution of your own and never initiate it. (I am telling them to be like me.) They have found this surprisingly hard to do. I was somewhat surprised to learn how preoccupied with gender some of these parents were — wanting to bombard their children with e-mails about the negative effects of surgery and hormones, among other things. I would receive late night phone calls begging my permission to send such destructive missives. On the question of pronouns and names, my advice was to avoid them as much as possible. There is rarely a need for the noun of address when the child is in the room, and artful dodging can elide gendered pronouns more often than you think. I do not favor explicitly agreeing to a, trans child’s requests to modify language and naming. Such agreements are usually infested with dishonesty — parents have not really agreed to a name or gender change, they are just succumbing to pressure — and the unconscious meanings behind the linguistic surrender are very hard to disentangle. Punting and honesty are usually better.
Sources other than Schwartz do not recommend “punting” or avoiding conversations about gender with your gender-diverse child. Instead, the UK’s NSPCC emphasizes the importance of engaging in these conversations with a child:
It can help to listen actively and respectfully to show them you’re truly involved. Try to ask open questions that don’t have yes or no answers and not to interrupt them. It’s important to keep the conversation about their feelings, and to avoid offering opinions or advice. . . . Some children or young people may find it difficult to talk about how they’re feeling about their gender identity. It can take a lot of courage for them to start the conversation and sometimes they may not feel comfortable sharing everything straightaway. Be patient and try not to rush them. Instead let them know that you’re there if they want to continue the conversation at a different time.
The Mayo Clinic similarly recommends:
If your child is persistent about gender identity feelings, listen. Talk to your child and ask questions without judgment. . . . Speak positively about your child to your child and to others. Show your admiration for your child’s identity and expression of it. By allowing your child to demonstrate preferences and share them, you’ll encourage a positive sense of self and keep the lines of communication open. . . . Whatever your child’s gender identity, do your homework and seek appropriate care. Showing your love and acceptance will also help your child feel comfortable in his or her body and in the world
And the American Academy of Pediatrics recommends:
When your child discloses their identity to you, respond in an affirming, supportive way. Understand that although gender identity is not able to be changed, it often is revealed over time as people discover more about themselves. Accept and love your child as they are. Try to understand what they are feeling and experiencing. Even if there are disagreements, they will need your support and validation to develop into healthy teens and adults. . . . Celebrate diversity in all forms. Provide access to a variety of books, movies, and materials — including those that positively represent gender diverse individuals. Point out LGBTQ celebrities and role models who stand up for the LGBTQ community, and people in general who demonstrate bravery in the face of social stigma. Support your child’s self-expression. Engage in conversations with them around their choices of clothing, jewelry, hairstyle, friends, and room decorations.
Schwartz’s recommendation of “punting” also appears to contradict FLDOH’s own position that “Children and adolescents should be provided social support by peers and family and seek counseling from a licensed provider.” Instead, Schwartz has maintained that families should almost entirely withhold support from their trans and gender-questioning children. The public deserves clarification of the FLDOH’s position on whether parents should support their kids, or opt for “punting” this basic parental responsibility.
FLDOH’s anti-trans guidance cites several sources which actually support access to gender-affirming care
The Florida Department of Health’s guidance declares:
One review concludes that “hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact is generally lacking.” . . . Social gender transition should not be a treatment option for children or adolescents. Anyone under 18 should not be prescribed puberty blockers or hormone therapy.
This obnoxious formatting implies that the linked resources support these positions. That is false: most of these sources clearly contradict the FLDOH guidance and do not recommend against social transition, puberty blockers, or hormone therapy for those under 18.
Sievert et al. (2021) do not oppose social transition for children or adolescents
FLDOH cites Sievert et al. (2021) in asserting:
Social gender transition should not be a treatment option for children or adolescents.
But Sievert et al. do not support this statement at all. The sample in this study consisted of gender-dysphoric children aged 5–11, not adolescents. The authors emphasize “the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling” and does not take a position against social transition. Instead, the authors cite two prevailing approaches to gender dysphoria, one which recommends social transition as an option for adolescents but not children, and the other recommending social transition as an option for both:
For example, de Vries and Cohen-Kettenis (2012) recommended for young children to not yet make a complete social transition before the very early stages of puberty. In contrast to this clinical management, a more gender affirmative approach freely endorses social transitions when they are perceived as appropriate (Ehrensaft et al., 2018; Giordano, 2019).
The clinic in this study states that in their practice, they allow for the possibility of social transition for children as well as medical treatment such as puberty blockers or hormone therapy for trans adolescents:
The Hamburg GIS for Children and Adolescents at the University Medical Center Hamburg- Eppendorf was founded in 2006 (Möller et al., 2014). All treatment performed at the clinic comply to the international guidelines for the SoC 7 released by the World Professional Association for Transgender Health (WPATH) in 2012 by Coleman et al. (2012). Clinicians follow a diagnostic and treatment protocol that was developed and in the past referred to as the “Dutch Model” (Cohen- Kettenis et al., 2011; Delemarre-van de Waal & Cohen-Kettenis, 2006; de Vries & Cohen-Kettenis, 2012). This clinical management approach suggests a watchful-waiting approach which differentiates counseling in contrast to a more gender affirmative treatment approach during adolescence (Cohen-Kettenis et al., 2008; Edwards-Leeper, 2016; Giordano, 2019). Sessions may include clinical diagnostics, counseling, psychotherapy and psychoeducation during childhood, as well as the possibility of referral to an endocrinology specialist for medical interventions after the onset of puberty. After a comprehensive diagnostic and psychological evaluation over multiple sessions, medical interventions are currently recommended in Hamburg if GD during adolescence is persistent (without strict onset criteria) and accompanied by distress, if adolescents present the ability to consider and anticipate treatment options as well as possible consequences of a life in the preferred gender role. The psychosocial treatment modalities are based on a psychodynamic and developmental perspective and similar to a supportive watchful-waiting approach. This means that steps of social transition during childhood are supported in individual cases, when the family is open to such a step and if a child clearly expresses the desire to proceed to live in their experienced gender. Decisions are never being made by a clinician alone, but in line with current SoC7, where clinicians, children and parents identify the best individual pathway together (informed consent), and in relation to the personal social circumstances (Coleman et al., 2012). Psychotherapy offered include psychodynamic individual and family sessions with a frequency tailored to the child’s individual needs.
Sievert et al. explain that while an individual child’s status of social transition was not directly found to be predictive of improved outcomes, support from parents, family, and peers was associated with better psychological functioning in trans and gender-questioning youth:
At the same time, however, most of this previous clinical research from Europe has not explored the possible role of the social transition status for psychological functioning outcomes. Nowadays, the two main explanations for elevated vulnerability and distress within this group are the state of conflict between one’s self-understanding of one’s gender and physical appearance on the one hand (Aitken et al., 2016), and lacking social support or poor peer relations (PPR) on the other hand (Aitken et al., 2016; Cohen-Kettenis et al., 2003; de Vries et al., 2016; Levitan et al., 2019; Steensma et al., 2014). Considering that gender nonconforming behavior is often evaluated negatively by peers, children with a GD diagnosis often experience a lack of social support from their peers or PPR, which in turn is associated with poorer psychological functioning. Family support or good general family functioning (GFF) levels on the contrary, may act as a protective factor against such health risks in youth with a GD diagnosis (Levitan et al., 2019; Simons et al., 2013). For example, in a population of 66 American adolescent transgender youth, parental support was significantly associated with higher life satisfaction, lower perceived burden related to being transgender and fewer depressive symptoms (Simons et al., 2013).
And the authors specifically note that this sample largely consisted of children who were strongly supported by their families, and these results may not be applicable to children whose gender identity is not supported:
Caution is also warranted in generalizing the results to all children with a GD because of the small and relative unique sample. All 54 children in the analysis sample were referred to the clinic for their GD, most of them came from families with a medium or high socio-economic background and the family support of the children’s gender identity was generally high. Due to the health care situation in Germany for children and adolescents with a GD diagnosis, some families go to considerable length to get access to treatment which they probably would not do if they did not generally support their child’s personal situation. At the same time, the clinical guidelines of the Hamburg GIS are quite liberal and allow for individual treatment pathways. Thus, these findings might not apply to a more diverse sample of transgender children who are not supported in their gender identity or expression by parents or clinicians, or children who identify themselves on a broader gender spectrum.
Nothing in this source cited by the FLDOH supports the position that social transition should be withheld from children or adolescents. Rather, the authors conclude that families, peers, and communities should support gender-dysphoric youth as their development unfolds:
Interventions targeted at reducing stigmatization among children and adolescents in the general population and at schools are essential, since children with a GD diagnosis often lack peer support (Cohen-Kettenis et al., 2003; Steensma et al., 2014) and transgender adolescents are more likely to be bullied at school (Toomey et al., 2010). Both peers and family should be incorporated in the psychosocial treatment of this population as early as possible, because incorporating parents’ needs and feelings in the psychotherapeutic process could improve the child’s situation as well. Parents themselves can be affected by their child’s GD and may experience parenting stress (Kolbuck et al., 2019).
Although claims that gender affirmation through transitioning socially is beneficial during this early stage could not be supported from the present results, supporting this step may still be considered in individual cases and together with the whole family. A clinical approach that considers children to explore their identity without strict criteria, but with an open mind, may allow for a discussion of all possible outcomes and individual strategies of exploring gender identity during childhood.
The FLDOH’s source thoroughly contradicts the FLDOH’s own guidance against social transition, puberty blockers or hormone therapy for anyone under 18; instead, all of these are recognized as important options that should be available to trans youth.
Chew et al. (2018) say puberty blockers work and withholding them is unethical
Citing Chew et al. (2018), FLDOH writes:
One review concludes that “hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact is generally lacking.”
However, this quotation from Chew et al. was referring to evidence regarding the psychosocial and cognitive impact of hormone therapy specifically — not puberty blockers. The authors went on to conclude that puberty blockers have positive physical and psychosocial effects, and hormone therapy has positive physical effects:
GnRHas successfully suppressed endogenous puberty, consistent with the primary objective of this treatment, although there was only a single study in which researchers actually recorded these data. GnRHas were observed to be associated with significant improvements in global functioning, depression, and overall behavioral and/or emotional problems but had no significant effect on symptoms of GD. The latter is probably not surprising, because GnRHas cannot be expected to lessen the dislike of existing physical sex characteristics associated with an individual’s birth-assigned sex nor satisfy their desire for the physical sex characteristics of their preferred gender. Like GnRHas, the antiandrogen cyproterone acetate effectively suppressed testosterone in transfemale adolescents, but its potential psychosocial benefits remain unclear. Meanwhile, GAHs increased estrogen and testosterone levels and thus induced feminization and masculinization, respectively, of secondary sex characteristics. However, in the case of breast development, the outcomes were subjectively less in size than expected in the majority of recipients, and the potential psychosocial benefits of GAHs remain unknown.
They recommend additional studies with larger sample sizes and tracking of more outcome measures:
Large, prospective longitudinal studies, such as have been recently initiated, with sufficient follow-up time and statistical power and the inclusion of well-matched controls will be important, as will the inclusion of outcome measures that investigate beyond the physical manifestations.
Of note, this source highlights the challenges of conducting randomized controlled trials of puberty blockers and hormone therapy given that withholding this care is unethical:
In this regard, although randomized controlled trials are often considered gold standard evidence for judging clinical interventions, it should be noted that, in the context of GD in which current guidelines highlight the important role of hormonal treatments, conducting such trials would raise significant ethical and feasibility concerns.
The FLDOH has not provided accurate context for its quote, and this source also does not support the FLDOH’s recommendation that puberty blockers or hormone therapy should be withheld from those under 18.
Carmichael et al. (2021) present limited and ambiguous data on puberty blockers
The FLDOH asserts:
Carmichael et al. (2021) is cited in supported of this statement. This study reports a null result for improvement in measured psychological functioning or quality of life (no change) in 44 youth aged 12–15 during the time they were treated with only puberty blockers (median 31 months, range 12–59) and prior to hormone therapy. Because of the limitation that there was no control group from whom puberty blockers were withheld, this study does not provide sufficient information to distinguish between a number of possibilities. One is that puberty blockers alone actually may not improve psychological functioning in this group; another is that puberty blockers did prevent an expected decline in psychological functioning over this time that typically seen among cis youth in this age range. The authors discuss these possibilities:
Psychological distress and self-harm are known to increase across early adolescence. Normative data show rising YSR total problems scores with age from age 11 to 16 years in nonclinical samples from a range of countries. Self-harm rates in the general population in the UK and elsewhere increase markedly with age from early to mid-adolescence, being very low in 10 year olds and peaking around age 16–17 years. Our finding that psychological function and self-harm did not change significantly during the study is consistent with two main alternative explanations. The first is that there was no change, and that GnRHa treatment brought no measurable benefit nor harm to psychological function in these young people with GD. This is consonant with the action of GnRHa, which only stops further pubertal development and does not change the body to be more congruent with a young person’s gender identity. The second possibility is that the lack of change in an outcome that normally worsens in early adolescence may reflect a beneficial change in trajectory for that outcome, i.e. that GnRHa treatment reduced this normative worsening of problems. In the absence of a control group, we cannot distinguish between these possibilities.
They further point out that distressing symptoms related to gender dysphoria and body image may not be alleviated by puberty blockers alone — instead, puberty blockers simply prevent the gender-incongruent development of natal puberty, while the gender-congruent development accompanying cross-sex hormone therapy does reliably produce positive changes:
Gender dysphoria and body image changed little across the study. This is consistent with some previous reports and was anticipated, given that GnRHa does not change the body in the desired direction, but only temporarily prevents further masculinization or feminization. Other studies suggest that changes in body image or satisfaction in GD are largely confined to gender affirming treatments such as cross-sex hormones or surgery.
Additionally, these youth reported that their experience of puberty blockers during this time was broadly positive and that they wished to continue treatment:
Young people’s reports of change in family and peer relationships were predominantly positive or neutral at both time points. Positive changes included feeling closer to the family, feeling more accepted and having fewer arguments. Those reporting both positive and negative change reported feeling closer to some family members but not others. At 6–15 months, negative family changes were largely from family members not accepting their trans status or having more arguments. But by 15–24 months only one young person reported this. Improved relationships with peers related to feeling more sociable or confident and widening their circle of friends; negative changes related to bullying or disagreements at school. Again, at 15–24 months only one young person reported negative change, related to feelings of not trusting friends.
At 6–15 months, changes in gender role were reported by 66% as positive, including feeling more feminine/masculine, living in their preferred gender identity in more (or all) areas of life and feeling more secure in their gender identity, with no negative change reported. At 15–24 months, most reported no change although 41% reported positive changes including experimenting more with physical appearance and changing their details on legal documents.
All young people affirmed at each interview that they wished to continue with GnRHa treatment. Note that this was also the case when asked routinely at medical clinics (excepting those who briefly ceased GnRHa as noted above).
The strongest interpretation of Carmichael et al. is that this is one neutral finding of neither harms nor benefits within the period of treatment with puberty blockers alone, among a body of mixed evidence with other studies also reporting clearly positive results during this treatment; Carmichael et al. also did not examine outcomes from later hormone therapy in this group. At no point do the authors find any cause for withholding all treatment with puberty blockers or hormone therapy before age 18 as the FLDOH recommends. Instead, as with several other studies cited by the FLDOH, this is a call for further research of trans youth receiving such treatments, with the intention of better informing their clinical care and resolving the uncertainties raised by the addition of this inconsistent finding to the literature. FLDOH’s use of this study implies that in a setting of uncertainty, they wish to withhold from trans youth a treatment that may be preventing further harm to them.
Goddings et al. (2014) does not address trans youth or use of puberty blockers
In claiming puberty blockers and hormone therapy should be withheld from anyone under 18, the FLDOH cites Goddings et al. (2014), “The influence of puberty on subcortical brain development”. This is a study of a series of brain MRIs of 275 presumably cisgender participants from ages 7–20 to track the changes of typical development during puberty; this was not a study of transgender youth and did not involve any use of puberty blockers or hormone therapy. FLDOH says of this study in its “Fact Check” press release:
According to a study in NeuroImage, “pubertal development was significantly related to structural volume in all six regions [in brain regions of interest] in both sexes,” meaning that the process of puberty is important to brain development.
The process of puberty being important to brain development does not argue for or against the use of puberty blockers or hormone therapy in trans youth under 18. These youth do not remain on puberty blockers indefinitely or avoid experiencing puberty altogether — the puberty of their identified sex is induced with cross-sex hormone therapy, the next stage of treatment following puberty blockers. The Endocrine Society’s treatment guidelines describe such a protocol for puberty induction in trans youth (Hembree et al., 2017):
Again, Goddings et al. did not examine the brain development of trans adolescents during treatment with puberty blockers or hormone therapy, and this source does not provide any apparent support for the position that “Anyone under 18 should not be prescribed puberty blockers or hormone therapy.”
Haupt et al. (2020) is largely about adult trans women, not use of puberty blockers
FLDOH also cites the Cochrane review “Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women” (Haupt et al., 2020), which encompassed only hormone therapy for trans women aged 16 and over, not the use of puberty blockers in adolescents:
We aimed to include randomised controlled trials (RCTs), quasi-RCTs, and cohort studies that enrolled transgender women, age 16 years and over, in transition from male to female. Eligible studies investigated antiandrogen and estradiol hormone therapies alone or in combination, in comparison to another form of the active intervention, or placebo control.
However, these criteria ended up encompassing no studies, with the authors concluding that under these terms they couldn’t say anything about the question either way:
As no studies met the inclusion criteria, we were unable to calculate any effects of the interventions.
By citing this source, the FLDOH is claiming that puberty blockers and hormone therapy should be withheld from anyone under 18 on the basis of a publication that wasn’t about puberty blockers or trans youth and did not provide any information about the outcomes of any gender-affirming care.
Kaltiala et al. (2020) studied adolescents and young adults who transitioned too late for puberty blockers
FLDOH cites Kaltiala et al. (2020) in its position that puberty blockers and hormone therapy should be unavailable to anyone under 18. However, Kaltiala et al. note that these youth were first diagnosed at a average age of 18.1 years (range 15.2–19.9) and all presented once the window for use of puberty blockers had passed, meaning all had experienced a gender-incongruent natal puberty. The authors cite this as a likely reason for the lack of change seen in the proportion showing good psychological functioning before and after treatment with hormone therapy:
What is more, even if the majority also functioned well in the domains studied during the first year on cross-sex hormones, no statistically significant improvements in functioning were observed in the group as a whole, and in the domain of peer relationships the share of those with normative contacts decreased. This is in disagreement with earlier studies suggesting improved functioning and reduced psychiatric symptoms in adolescent onset hormonal treatment of gender dysphoria, and likely due to older age, more difficult psychopathology and different intervention (cross-sex hormones vs. GnRH analogues) in our sample. Our subjects were all post-pubertal and halting of development was thus not possible.
Even so, this study found a significant decrease in trans youth’s need for treatment for depression, anxiety, and self-harm/suicidality at a one-year followup:
Need for treatment due to depression, anxiety and suicidality/ self-harm was recorded less frequently during the real-life phase than before it. This is in line with the conclusion of a relatively recent meta-analysis that in adults with gender dysphoria, cross-sex hormonal treatment alleviates anxiety, and may also reduce depression or depressive symptoms. However, need for psychiatric treatment overall did not decrease from the level before and during the gender identity assessment to the real-life phase. New needs had also emerged about as frequently as need for treatment diminished. . . . Depression, anxiety and suicidality/self-harm are often assumed to be secondary to gender dysphoria, and our findings may be interpreted as lending some support to that assumption among adolescents, similarly as earlier research seems to imply for adults.
The authors call for more comprehensive support for these youth in all aspects of their psychosocial health beyond addressing only gender dysphoria:
If the adolescents diagnosed with transsexualism had had difficulties at school/work as during the gender identity assessment, they mainly continued to have difficulties during the real-life phase. Only a minority moved from progressing with difficulties to progressing normatively, and equally many deteriorated during follow-up. Improved functioning as a consequence of alleviating gender dysphoria and passing better in the desired role is commonly assumed but has not previously been researched in relation to education/work. Our findings suggest that treatment of gender dysphoria does not suffice to improve functioning in education and working life. Difficulties in school adjustment and learning are common among gender-referred adolescents and often not properly addressed, on the assumption that treatment of gender dysphoria would relieve an array of problems. Educational difficulties need to be fully addressed during adolescence regardless of gender identity. . . . An adolescent’s gender identity concerns must not become a reason for failure to address all her/his other relevant problems in the usual way.
Notably, they do not call for gender dysphoria to go unaddressed by withholding puberty blockers or hormone therapy from this group. The FLDOH has cited a study of less than optimal improvements among youth who largely could not access puberty blockers or hormone therapy until after turning 18, and then declared on this basis that these youth should not be able to access puberty blockers or hormone therapy before turning 18. The FLDOH’s position is unsupported by this study or by the other studies cited, which most often reach the very opposite conclusion. Sloppy illusion and sleight-of-hand that falter under the gentlest examination are a completely unacceptable basis for policy or recommendations. The Florida Department of Health has failed the trans youth of Florida with this cruel joke of “guidance” from an unreliable guide. ■
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